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BOB WILSON MEMORIAL GRANT COUNTY HOSPITAL
CONTENT OF RECORD: FINAL DIAGNOSIS
Tag No.: A0469
The hospital reported an average daily census of 6.48 patients with a current census of two acute patients and three swing bed patients. Based on medical record review, Medical Staff Rules and Regulations and staff interview the hospital failed to ensure the providers complete a medical record within thirty days after discharge for three of thirteen discharged patients sampled (#3, #14 and #15). This deficient practice had the potential for inadequate post-hospitalization follow-up care.
Findings include:
- The hospital's Medical Staff Rules and Regulations reviewed on 6/3/15 at 2:30pm directed, " ...All discharge summaries shall be authenticated by the responsible practitioner ... if a medical record remains incomplete after 21 days, the practitioner shall be notified by mail that his admitting privileges shall be suspended seven days from the date of notice ... "
- Patient #3 ' s medical record reviewed on 6/3/15 revealed an admission date of 4/17/15 and a discharge date of 4/28/15 with diagnoses of weakness and debility. Patient #3's medical record revealed the Discharge Summary lacked the provider's signature. The medical record failed to be complete within 30 days as required.
- Patient #14's closed medical record reviewed on 6/3/15 revealed an admission date of 4/24/15 and discharged on 4/28/15 with diagnoses of Sinusitis (infection of sinuses) and UTI (urinary tract infection). Patient #14's medical record revealed the Discharge Summary lacked the provider's signature. The medical record failed to be complete within 30 days.
- Patient #15's closed medical record reviewed on 6/3/15 revealed an admission date of 4/20/15 and discharged on 4/28/15 with diagnoses of shortness of breath and pneumonia (infection in lungs). Patient #15's medical record revealed the Discharge Summary lacked the provider's signature. The medical record failed to be complete within 30 days.
Administrative staff A, interviewed on 6/3/15 at 1:45pm reviewed the medical records and confirmed the medical record failed to be completed within 30days for patients # 3, #14, and #15.